Point Prevalence Survey 2017 of healthcare-associated infections and antimicrobial use in Swiss

106 Pages·2017·1.19 MB·English

Hôpitaux Universitaires de Genève
Point Prevalence
Survey 2017 of
healthcare-associated
infections and
antimicrobial use in
Swiss acute care

hospitals

Coordination Center Prevalence Study CH
22/01/2018
Contents
Abbreviations ........................................................................................................................ 6
Executive Summary .............................................................................................................. 7
Introduction ........................................................................................................................... 8
1. The impact of Healthcare-associated infections on healthcare .................................... 8
2. Prevalence surveys as a means to assess the burden of healthcare-associated
infections .................................................................................................................... 8
3. The situation in Switzerland ........................................................................................ 8
4. Funding ....................................................................................................................... 9
Survey design and methodology ..........................................................................................10
1. Method and development of the Swiss PPS protocol .................................................10
2. Objectives ..................................................................................................................11
3. Inclusion and exclusion criteria for hospitals, wards, and patients ..............................11
Hospitals .......................................................................................................................11
Wards ............................................................................................................................11
Patients .........................................................................................................................11
4. Representative sample for comparison with the European countries participating in the
ECDC-PPS ................................................................................................................12
5. Validation survey .......................................................................................................12
Implementation .....................................................................................................................13
1. List of participating hospitals ......................................................................................13
2. Swiss PPS website ....................................................................................................15
3. Training-the trainor courses .......................................................................................15
4. Data collection ...........................................................................................................16
5. Data management .....................................................................................................16
Results .................................................................................................................................17
1. Hospital-level data .....................................................................................................17
A. Hospital characteristics ...........................................................................................17
B. Isolation capacity ....................................................................................................22
C. Staffing, workload, bed occupation .........................................................................26
D. Hand hygiene .........................................................................................................29
E. Microbiological laboratory performance ..................................................................32
F. Post-prescription review of antimicrobials ...............................................................34
G. Organisation of infection prevention and control .....................................................34
H. Organisation of infection prevention and control .....................................................40
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2. Patient level data .......................................................................................................42
A. Patient characteristics .............................................................................................42
B. Healthcare-associated infections ............................................................................56
C. Antimicrobial use ....................................................................................................87
References ......................................................................................................................... 105

Figures
Figure 1: Differences between point and periodic prevalence survey methods .....................10
Figure 2: Examples to include and exclude patients .............................................................12
Figure 3: Patient age by hospital size ...................................................................................42
Figure 4: Patient by hospital type .........................................................................................43
Figure 5: Prevalence of male gender by hospital size ...........................................................44
Figure 6: Prevalence of male gender by hospital type ..........................................................45
Figure 7: Patient McCabe score by hospital size ..................................................................46
Figure 8: Patient McCabe score by hospital type ..................................................................47
Figure 9: Patient McCabe score by hospital ownership ........................................................48
Figure 10: Length of stay to survey day ................................................................................49
Figure 11: Length of stay to survey day by hospital size .......................................................50
Figure 12: Length of stay to survey day by hospital type ......................................................51
Figure 13: Length of stay to survey day by University-Affiliation ...........................................52
Figure 14: Distribution of ward specialties ............................................................................53
Figure 15: Distribution of patient specialties .........................................................................54
Figure 16: Use of medical devices ........................................................................................55
Figure 17: HAI prevalence in Switzerland (all HAI, HAI during current hospitalisation) .........56
Figure 18: HAI prevalence in Switzerland (all HAI, excluding HAI from other hospitals, HAI
during current hospitalisation; stratified by observed and randomized sample) ....................57
Figure 19: HAI prevalence in Switzerland (with randomized and validated sample) ..............58
Figure 20: HAI prevalence by Canton ...................................................................................59
Figure 21: HAI prevalence by linguistic region ......................................................................60
Figure 22: HAI prevalence by Anresis Region ......................................................................61
Figure 23: HAI prevalence by hospital size ...........................................................................62
Figure 24: HAI prevalence by hospital type ..........................................................................63
Figure 25: HAI prevalence by hospital ownership .................................................................64
Figure 26: HAI prevalence by ward specialty ........................................................................65
Figure 27: HAI prevalence by age group ..............................................................................66
Figure 28: HAI prevalence by gender ...................................................................................67
Figure 29: HAI prevalence by McCabe score .......................................................................68
Figure 30: Prevalence of surgical site and device-associated infections ...............................70
Figure 31: Days to healthcare-associated infection ..............................................................71
Figure 32: Days to HAI by hospital size ................................................................................72
Figure 33: Days to HAI by hospital type ................................................................................73
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Figure 34: Days to HAI by University-affiliation .....................................................................74
Figure 35: Distribution of HAI types (835 HAIs) ....................................................................75
Figure 36: Distribution of HAI types by hospital size .............................................................76
Figure 37: Distribution of HAI types by hospital type .............................................................77
Figure 38: Distribution of HAI types by University-affiliation ..................................................78
Figure 39: Source for bloodstream infections by hospital size ..............................................79
Figure 40: Source for bloodstream infections by hospital type ..............................................80
Figure 41: Source for bloodstream infections by University-affiliation ...................................81
Figure 42: HAI prevalence attributed to the current ward by hospital size .............................82
Figure 43: HAI prevalence attributed to the current ward by hospital type ............................83
Figure 44: Proportion of HAIs for which microbiological tests were ordered on total number of
HAIs, and proportion of microbiologically documented HAIs .................................................84
Figure 45: Distribution of isolated microorganisms (by family name) ....................................85
Figure 46: Drug-resistant microorganisms among isolated microorganisms .........................86
Figure 47: Antimicrobial use, total and antimicrobial days ....................................................87
Figure 48: Antimicrobial use by canton .................................................................................88
Figure 49: Antimicrobial use by linguistic regions .................................................................89
Figure 50: Antimicrobial use by Anresis regions ...................................................................90
Figure 51: Antimicrobial use by hospital size ........................................................................91
Figure 52: Antimicrobial use by hospital type ........................................................................92
Figure 53: Antimicrobial use by hospital ownership ..............................................................93
Figure 54: Antimicrobial use by ward specialty .....................................................................94
Figure 55: Antimicrobial use by age group ............................................................................95
Figure 56: Patient on single antimicrobial or combination therapy ........................................96
Figure 57: Distribution of antimicrobials by indication ...........................................................97
Figure 58: Distribution of antimicrobials by medical diagnosis ..............................................98
Figure 59: Distribution of antimicrobial classes .....................................................................99
Figure 60: Distribution of antimicrobial classes used for community- and healthcare-acquired
infections ............................................................................................................................ 100
Figure 61: Ten most common antimicrobials ...................................................................... 101
Figure 62: Ten most common antimicrobials for therapeutic purposes ............................... 102
Figure 63: Ten most common antimicrobials for prophylactic purposes .............................. 103
Figure 64: Ten most common antimicrobials for surgical prophylaxis ................................. 104

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Tables
Table 1: Participating hospitals by canton in alphabetic order ...............................................13
Table 2: Training-the trainor courses schedule .....................................................................16
Table 3: Hospital size and number of patients included in the CH-PPS ................................18
Table 4: Number of available beds and patients included in the CH-PPS .............................19
Table 5: Hospital discharges in a given year ........................................................................20
Table 6: Length of stay (days) ..............................................................................................21
Table 7: Hospital rooms ........................................................................................................22
Table 8: Beds per hospital room ...........................................................................................23
Table 9: Proportion of single rooms (among all rooms) .........................................................24
Table 10: Proportion of single rooms with toilet and shower (among single rooms) ..............25
Table 11: Nurses per 100 hospital beds ...............................................................................26
Table 12: Nursing assistants per 100 hospital beds ..............................................................27
Table 13: ICU nurses per ICU bed........................................................................................27
Table 14: ICU nursing assistant per ICU bed ........................................................................28
Table 15: Ward occupation at midnight ................................................................................28
Table 16: Alcohol-based handrub consumption ....................................................................29
Table 17: Alcohol-based handrub (dispensers) at the point of care ......................................30
Table 18: Observed hand hygiene opportunities per year and hospital .................................31
Table 19: Blood culture sets per 1000 patient-days ..............................................................32
Table 20: Stool tests for identifying Clostridium difficile infections per 1000 patient-days .....33
Table 21: Microbiological tests on weekends ........................................................................33
Table 22: Infection Prevention and Control – Annual plan ....................................................34
Table 23: Infection Prevention and Control – Annual report ..................................................35
Table 24: Infection Prevention and Control nurse – Full time equivalent per 250 beds .........36
Table 25: Infection Prevention and Control doctor – Full time equivalent per 1000 beds ......37
Table 26: Antimicrobial stewardship – Full time equivalent per hospital ................................38
Table 27: Surveillance activities ...........................................................................................39
Table 28: Multimodal strategies in intensive care: single elements .......................................40
Table 29: Multimodal strategies in intensive care: combination of elements .........................40
Table 30: Multimodal strategies outside intensive care: single elements ..............................41
Table 31: Multimodal strategies outside intensive care: combination of elements .................41
Table 32: Univariable and multivariable analysis of risk factors for HAI ................................69

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Abbreviations
ABHR Alcohol-based hand rub
AU Antimicrobial use
BSI Bloodstream infection
CAUTI Catheter-associated urinary tract infection
CDI Clostridium difficile infection
CRF Case Report Form
CH Switzerland
CH-PPS Swiss Point Prevalence Survey
CLABSI Central line-associated bloodstream infection
CVC Central venous catheter
ECDC European Centre for Disease Prevention and Control
EU European Union
FOPH Federal Office of Public Health
HAI Healthcare-associated infection
HCW Healthcare worker
HH Hand Hygiene
HUG University Hospitals of Geneva (Hôpitaux Universitaires de Genève)
ICU Intensive care
IPC Infection Prevention and Control
IQR Interquartile range
KISS Krankenhaus Infektions Surveillance System
LRTI Lower respiratory tract infection
MDRO Multidrug-resistant organism
NHSN National Healthcare Surveillance Network
PABSI Peripheral line-associated bloodstream infection
PPS Point Prevalence Survey
PRIM Primary care
PRIVFP Private ownership, for-profit
PRIVNFP Private ownership, not-for-profit
PROHIBIT Prevention of hospital infections by intervention and training
PUB Public hospitals
PVC Peripheral venous catheter
SEC Secondary care
SENIC Study on the Effectiveness of Nosocomial Infection Control
SPEC Specialised care
SSI Surgical site infection
TERT Tertiary care
UC Urinary catheter
US United States
UTI Urinary tract infection
VENT Ventilator
WHO World Health Organization
95%CI 95% confidence interval

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Executive Summary
Between April and May 2017, 96 acute care hospitals in Switzerland performed a joint point
prevalence survey on healthcare-associated infections (HAIs) and the use of antimicrobials.
The average HAI-prevalence was 5.9% in 12’931 patients, and 33% received one or more
antimicrobials on the day of survey. The prevalence of patients with HAI onset during current
hospitalisation was 4.2%. These numbers are similar to the past European Centre for
Disease Prevention and Control (ECDC) point prevalence survey in 2011/2012. The most
common healthcare-associated infections were surgical site infections (29%), lower
respiratory tract infections (18%), urinary tract infections (15%), and bloodstream infections
(13%). The highest proportions were identified in intensive care units (20.6%), in large
hospitals (7.8%), in elderly patients (7.4%), in male patients (7.2%), and in patients with
ultimately (9.3%) or rapidly (10.6%) fatal outcomes.
Most antimicrobials on the day of survey were administered to treat infections (62%). The
remainders were used for prophylaxis either before surgery (77%) or for medical purposes
(23%). More patients in intensive care were on antimicrobials (62%) compared to surgery
(44%), internal medicine (32%), and paediatrics (31%). These findings are in mid-range
compared to Europe. Two thirds of the hospitals have formalized antimicrobial stewardship,
but only 9% perform post-prescription review of antimicrobials, one of the key actions of
antimicrobial stewardship.
Only half of the hospitals (53%) had an annual plan for infection prevention and control (IPC),
but two thirds (64%) produced an annual report summarizing IPC activities. Staffing of IPC
nurses in Swiss hospitals was 1.5 per 250 hospital beds in 2017. This is higher compared to
other European countries where average staffing is 1 per 250 hospital beds. Staffing for IPC
doctors in Switzerland was 2.5 per 1000 hospital beds in 2017. Average consumption of
alcohol-based handrub was 53 mL per patient-day. Although there is room for improvement,
this was far more than the 21 mL per patient-day identified in past European surveys.
The survey in 2017 was part of the priority given on HAI-prevention by the strategy
“Gesundheit 2020/Santé 2020” of the Swiss Confederation. The survey was organised by
Swissnoso with financial support by the Federal Office of Public Health. The last survey on
HAI in Switzerland was performed in 2004. Although the methodologies between the two
surveys in 2004 and 2017 were different and comparison of the results difficult, healthcare-
associated infections are likely to have decreased since. The protocol of the survey in 2017
followed the ECDC methodology, which was developed jointly by different stakeholders, and
which was used concurrently in surveys on HAI and antimicrobial use in other European
countries. This will allow benchmarking with countries in Europe as soon as ECDC will
publish the results by the end of 2018.

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Introduction
1. The impact of Healthcare-associated infections on healthcare
Healthcare-associated infections (HAIs), also known as “nosocomial” or “hospital-acquired
infections” are infections acquired in healthcare settings, which neither are present nor
incubating at the time of hospital admission. They are associated with attributable mortality,
and have a negative impact on clinical outcome, length of stay, and hospital costs.
Healthcare-associated infections are accepted to have a major impact on patient safety, and
today, a growing number of countries address HAIs as a priority patient safety topic.
The overall HAI burden remains high, albeit much effort has been devoted to their
prevention. According to the World Health Organization (WHO), 7% of patients in developed
countries and 10% in developing countries will acquire at least one HAI at any one time, with
attributable mortality estimated at 10%.1
2. Prevalence surveys as a means to assess the burden of healthcare-
associated infections
Prevalence surveys have a long tradition in the field of infection prevention and control (IPC).
In the early 70's, the Center for Disease Control and Prevention (CDC) Study on the
Effectiveness of Nosocomial Infection Control (SENIC) in the United States used repeated
point prevalence surveys (PPSs) to measure the effectiveness of infection prevention and
control programmes on a number of HAI outcomes such as surgical site infections (SSIs),
bloodstream infections (BSIs), urinary tract infections (UTIs), and lower respiratory tract
infections (LRTIs) in more than 300 US hospitals.2 Already in 1981, WHO experts
recommended performing national PPSs as a tool to estimate the burden of HAI at
reasonable cost.3 Although the response to this call was moderate at that time, a growing
number of countries have conducted national surveys in subsequent years. In the 90’s and at
the turn of the millennium, PPSs have gradually fallen into oblivion until the European Centre
for Disease Prevention and Control (ECDC), and the US Center for Disease Control (CDC)
performed large-scale, surveys in 2011/2012. The prevalence in the US and in the European
Union (EU) was 4% and 6%, respectively.4-6 Between 2016 and 2017, ECDC performed its
second PPS on HAI and antimicrobial use in the European Union, the European Economic
Area, and EU candidate countries.
3. The situation in Switzerland
In Switzerland, a series of national HAI prevalence surveys had been carried out by
Swissnoso in the past, the last in 2004.7-14 In contrast to most other countries using the point
prevalence methodology, Switzerland used the period prevalence methodology, which did
not allow benchmarking, neither to other surveys nor to the present CH-PPS. The period
prevalence methodology inflates the number of identified HAI by providing a more
appropriate distribution of HAI-types.15
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In January 2013, the Swiss Federal Council approved the ‘Health 2020' plan, setting priorities
in public health over the upcoming years. Within this plan, HAI prevention was given high
priority, and as a consequence, the federal office of public health (FOPH) together with a
large number of stakeholders from health delivery, defined the “Strategy NOSO”, which was
validated by the Swiss Federal Council in 2016.16 The objective of the strategy is the
reduction of HAIs and prevention of emerging resistance in Swiss acute-care health facilities.
In order to get data on the burden of HAI in Switzerland, the FOPH encouraged and
supported Swissnoso to perform a national PPS. Swissnoso on its part engaged the
University of Geneva Hospitals (HUG) to coordinate the task. Given that ECDC was about
performing its second PPS, Switzerland should provide comparable data still in 2017.

4. Funding
This survey was organized by Swissnoso in collaboration with the University of Geneva
Hospitals. Swissnoso received financial support by the Swiss Federal Office of Public Health
to conduct this study.

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Survey design and methodology
1. Method and development of the Swiss PPS protocol
The applied method follows a classic point prevalence protocol. Compared to the period
prevalence methodology used in the past, data are collected on one day only (snapshot),
instead of looking at a time window of 7 days. While the period prevalence method captures
more HAIs, particularly those of short duration, it is a mix between the concepts of
“prevalence” and “incidence” and inflates the overall burden of HAI.15 Furthermore, it is also
more time-consuming than PPS.
The Swiss‐PPS used the standard version of the second ECDC-PPS as described in the
ECDC Protocol version 5.3 for the ECDC‐PPS II.17 In addition to previous surveys, the
second ECDC-PPS addressed hospital indicator data based on ten key components,
identified by a large ECDC-initiated systematic review and expert consensus.18 The protocol
was translated into the three official Swiss languages (German, French and Italian) by the
coordinators and the IPC team at Lugano Civico Hospital. A few minor modifications were
applied to adapt the protocol to the situation in Switzerland (particularly in the section about
hospital indicators). The protocol, as well as the code lists for HAIs, microorganisms, and
antimicrobials, can be downloaded from the CH-PPS website www.swissnoso.ch/prevalence.
The protocol addresses four areas of interest: 1) hospital indicator data; 2) patients’
demographics, characteristics, and risk factors; 3) HAIs, and 4) antimicrobial use.

Figure 1: Differences between point and periodic prevalence survey methods

Adapted from Zingg and colleagues 15

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